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NPI Code Detail

MEDICARE: MRS. AMANDA LEE GIBSON OTRL

MEDICARE: MRS. AMANDA LEE GIBSON OTRL
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225X00000XOccupational Therapist056006623IL
2225XP0200XPediatric Occupational Therapist056006623IL

General Provider Information

NPI Number : 1336204932
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. AMANDA LEE GIBSON OTRL
Provider Business Mailing Address
First Line : 595 BASSWOOD LN
Second Line :
City : NORMAL
State : IL
Zip : 61761-5749
Country : US
Telephone Number : 630-272-0311
Fax Number :
Provider Business Practice Location Address
First Line : 1606 HUNT DR
Second Line :
City : NORMAL
State : IL
Zip : 61761-2192
Country : US
Telephone Number : 309-451-0069
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/26/2006
Last Update Date : 10/17/2011

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Directions to “ MRS. AMANDA LEE GIBSON OTRL” Practice Location

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